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Sunday, January 31, 2016

High-End
Immigrants: TheirInsight into America

A
moment’s insight is sometimes worth a life’s experience.

O.W. Holmes
(1809-1894),The Professor at the Breakfast Table

I’ve been reading a book, The Road to Home, by Vartan Gregorian, Simon & Schuster, 2003

Vartan Gregorian is an 81
year old Armenian immigrant who migrated to the U.S at age 22 in 1956, earned a PhD in History at Stanford, held
professorships at 4 American universities,became President ofBrown
University,the New York Public Library,
and the Carnegie Foundation.

I mention these accomplishments because Dr. Gregorian, like
many highly skilled and learned immigrants,had the insight
to instantly recognize America’s greatest assets – its limitlessopportunities,its freedoms to rise, and its immeasurable natural
human and physical resources.

Here is Gregorian giving his insights upon his arrival:

“My first impressions of Americans during my first two
months were many and varied.I wrote in
my diary that Americans don’t like to be bossed or told what to do by
anyone,nor their government nor their
clergy or their employers.They must
believe they are acting on their own volition.Americans are very individualistic.They work hard, they are open, kind, and generous.”

And here is Gregorian, sharing his views after assuming a professorship at the
University of Texas and living in Austin.
“Texas was huge! It was an endless frontier. It was a proud, self-confident,
optimist state. It was the land of “Why not?” and “can do.” Whether youknowit or not,while in Texas you had
to think big. With size went a swaggering boastfulness…Texas had the biggest
horizons, the biggest skies, and the largest number of stars.In Texas, you never felt constrainedYou never felt claustrophobic The whole state was restless and on the move.”

More than anything else immigrants recognize America as the
land of opportunity, of "why not?" and "can-do."

Peter F. Drucker (1909-2005), an Austrian immigrant and the
father of management as we know it,said
it best on how to succeed in American business.

“Courage
rather than analysis dictates the truly important rules for identifying
priorities;

·Pick the future as against the past.

·Focus on opportunity rather than on problem.

·Choose
our own direction – rather than climb on the bandwagon.

·Aim high, aim for something that will make a difference, rather
than for something that is 'safe' and'easy' to do.”

hHighly
skilled immigrant entrepreneurs recognize America as their future homeForty-three percent of Silicon Valley
founders and CEOs are immigrants.These include Sergey Brin, co-founder of
Google, and Safra Catz, CEO of Oracle.Small wonder that Silicon Valley lobbyists are fighting a running battle
to loosen restrictions on H-1 visas for entrepreneurs from abroad.

bBefore I end this blog post,let me
remind readers that 25% of physicians practicing in America are foreign-trained
immigrants, including anesthesiologists,
31%, cardiologists, 31%.,internists, 32%., nephrologists, 40%, psychiatrists, 31%, family physicians, 35%. Immigrant doctors too want to share the American dream of freedom and opportunity.

Saturday, January 30, 2016

The world is being turned upside-down and inside-outin the world of politics,as well as the worlds of business andhealth care.

The act of inversion is to reverse positions, directions, or
relationships,to turn inside-out, or
upside-down, or topsy-turvy

In politics,Donald Trumpand the Bernie Sanderslead the
inversion list.Suddenly,Trump, a businessman with no direct, inside political experience,and Sanders,a long-avowed Democratic Socialist with 25 years in Congress, but also no political insider, are suddenly leading their respective
political parties.Bothare political outsiders leading“revolutions,”and new political merry-go-rounds, whether
they will stop nobody knows.Trump
appeals tolower and middle class
working voters, who have tired and suffered fromeconomic slow growth and unfulfilled
government promises,andSanders attracts the young, idealistic,and the liberal elite, who believe in or seek government largesse and power using other people’s money.

In business, inversion goes
by the name of tax inversions, whereby corporations relocate their headquarters
in a lower tax nation, or corporate haven ,while maintaining their operations in the higher tax nation.This is often done by acquiring a company
in the lower tax nation.In the $100
billion dollar Pfizer-Allergen deal,Pzifer would lower its overall-tax burden from 25% tp 17%,saving $1 billion in the process.Fifty one companieshave done tax inversions,including Tyco International,Pfizer, Medtronic, and Burger King,and other big companiesare considering tax inversion.The driving force isthe punitive U.S. corporate income tax,
which,at 35%, and effectively 39%, is
the highest in the world.For mostcompanies, the favored corporate havens are
Ireland,the U.K,Jamaica, or elsewhere in the Carribean, and
in the case of Burger King,Canada.

With health care,pharmaceutical companies and health care corporationsfavor Ireland as a haven.With hospitals, physicians, and consumers
the inversionsare relocations to a
different site or a different way of practice within the U.S.Hospitals seek markets and switches of
operating sites outside the hospitals,often in acquiredphysician
practices and generally in the suburbs orregions or states in which they dominate. Physicians tend to convert traditional
practicesto direct, cash-only
practices, outside the reach or participationin 3rd party government or insurance programs. Asfor consumers,who can no longer affordhigh
premiums or deductibles,the inversion
targets are home care,direct cash
practices, self-care, or reliance on the Internet for information and
self-monitoring devices.One side
prides itself on following the dictates of its conscience and its moral imperatives,other on its common sense and its state of
economic despair.

The U.S. economy grew by only 0.7% of GDP in the last
quarter,and it has only grown by 2.0%
in the last 7 years, the slowest economy recovery from a recession since World
War II.To be fair,under Obama, recovery has been sluggish,
fitful, faltering, and historically weak but it’s a recovery nevertheless, perhaps
justified on moral grounds. Slow growth
has led to stagnant incomes, to economic anxiety, to political unrest to
reduced health care access.

Is this slow growth due to Obama’s economic policies,GOP obstructionism,or factors beyond his control, such as the
slow growth of the world’s economy?Does the U.S, highest corporate income tax in the world contribute?What about those inversions ;that are driving major U.S. corporations abroad to avoid high U.S. taxes? What about the $500 billion in 20 new taxes attributed to ObamaCare or those 8200
pages of new regulations on business?

Would lowering taxes and lightening regulations “lift all
boats”? Would these moves alleviate the economic
burdens on the middle class whose
incomes have shriveled by 10%? Would a smaller government placate the rise
gorge of populist anger? Or will it take a socialistic government to dampen the
revolt among the young and idealistic?

Or would these moves lead to increased income inequality between
the rich and poor and middle class?

Is there in inverse
relationship between government growth and economic growth?Is there something to the saying that if you
tax something more you will get less of it? Of is the Laffer Curve simply
laughable? Is the economy trickle-down or bubble -up?

Economic growth, lack
of it, or unfairness of itare the key issues in the 2016 elections.

On the Democratic side,the candidates are saying economic growth is good but not if it produces
unfairness.Taxes on the rich and on the middle class are necessary to right the
social ship, even, in the case of Bernie Sanders,it comes at the cost of $18 trillion to
provide Medicare- for-all and free –college- tuition- for-all and other assorted government goodies.

That’s too much ballast for the U.S. Ship of State,say GOP candidates.A rising tide lifts all boats.Economic growth, not fairness, is the number one political issue.Liftthat boat,tote that barge,lighten those taxes and regulations,and growth will soon lift to 4% rather than an anemic2%.And all interests, for the rich, the middle class, and poor will be
served

Says George Will, it’s a matter of simple arithmetic (The
Simple Arithmetic That Could Jump-Start America’s Economic Growth.” Washington Post, January 29, 2015).And observed Lewis Carroll in Alice in
Wonderland 150 years before Will,“Reeling
and Writhing, of course, to begin with, and the different branches of
Arithmetic – Ambition, Distraction, Uglification, and Derision.”

Slow growth and how to speed it up is an ugly
business,with plenty of mixed motives to go around. Economic growth is a messy business. But, given the resilience of a freedom-loving entrepreneurial nation, we’ll meddle and muddle through.

Friday, January 29, 2016

DIY (Do-It-Yourself) Health Care Technologies

In
recent years, do-it-yourself (DIY) health care technology has become a topic of
speculation…as smart devices and wearable technology promise homes,
workplaces,and mobile phones into more
accessible sites for home monitoring and intervention

Jeremy
Greene, MD, PhD, General Internal Medicine, Johns Hopkins University School of
Medicine,“Do-It-Yourself Medical
Devices and Empowerment in American Health Care,” NEJM, January 28, 2015

You can never tell what people will do when left to their
own devices,to do what they want to do
without external control. I am talking about DYI (Do-It-Yourself)medical devices, which allow you to do for yourself what doctors would otherwise do for you.

In his January 28 NEJM article,Doctor Greene concludes, “It’s important to remember that DYI medical
technologies are neither wholly new or wholly liberating. And in offering another
means of circumventing physicians , they may well expose patients to new costs and
new risks.”

Lately DYI has experienced a renaissance as health reform
see it as a way of reducing costs by letting consumers to their thing without
doctors.PriceWaterHouseCoopers, the
giant accounting and consulting firmranks it number 1 among health care developments in 2015. Qualcomm,
another giant health care firm is offering$10 million competition prize to “stimulate innovation and integration
of precision diagnostic technologies , helping consumers make their own
reliable health diagnoses anywhere, anytime.

I am one of those consumers, and I am having trouble
deciding whether to monitor myself.I
recently received a free small box, 2” by 5”, courtesy of Castle Connolly Ltd, a health care publishing
and consulting company given to me as a gift for serving on their medical advisory board.

The performance monitor had 2 menu screens for general navigations,
a monitor with a touch screen, an infrared temperature sensor, an internal SpO2
sensor, a home button to turn the monitor on or off, a multifunction
connectors, 3 ECG electrodes, , andneck
strap hole to allow me to measure my vitals and their responses anytime
anywhwere.

At the bottom of the box was a neck strap and an 18”
electrical cord , one of which plugs into the device and the other into I know
not what

I have 3 problems with the device.

One,the instructions
don't tell me what to plug it into, rendering it inoperable.

Two,I am having a hard
time following the directions how to use and have frittered away an hour or so
trying to learn how.

Three,I do not want
to know myvitals, my response to
exercise, my oxygen levels, number of steps taken, or my temperature.

I have asked a young geek to show me how to use it.After he teaches me,I will give it to him.I am one who is out-of-step and out-of-time with DYI technologies, which
have their place but not in my space. As for others, it's up to you, to do unto yourself what others would do unto you.

Thursday, January 28, 2016

Have you ever wondered about the lack of national commitment
to health reform?

Well,I have.

After all, this nation committed itself to developing the
atomic bomb,to putting a man on the
moon,to winning the Cold War, surely
should be able to committee itself to national health.

Why not health
reform?Our health affects us all, and we all want to retain our
health , prevent disease, and ward off death as long as we can.

I have come to these conclusions.

One,health reform is a personal,
not a collective matter. Given human nature,most of us act out of personal
self-interest rather than collective interest. And as Adam Smith pointed out in
the Wealth of Nations,personal economic self-interests raises
everybody’soverall interests.

Two, with
health reform,there is no external
threat to our nation’s personal health, no competition with other nations
related to our personal existence or health or survival.

Three,health reform, Obama style, is dedicated to
covering 14% of the uninsured population,but when it was launched, 86% were satisfied with their health care.Those numbers persist to this day.

Four,human behavior is predicated on the notion
of the survival of the fittestand the
winnowing out of the less fit.In a free
enterprise competitive society,neither
compassionate liberalism or compassionate conservatism works very well. This
truth is too bad, but it exists.

Five,in a pragmatic center-right capitalistic
nation,results are more compelling than
rhetoric,no matter who nobleor eloquent.Reform is expensive, in the neighborhood of $1 trillion spread over 10
years, and its results in improving health so far are not impressive.As a cynic said, “when they say it’s the
principle and not the money, it’s the money.”

Six,lack of bipartisan agreementabout how to go about introducing reformor how to calculate its long-term costs,hampers its implementation in an impatient nation, that
developed an Atomic Bomb in 5 years, won
World War II in 4 years and put a man on the moon in 7 years.

Seven,somehow the scientific
approach - computer-collected metadata
as a means of guiding and paying for health care, thoughobjective and admirable in its way because of its lack of emotional, moral, and political
content,lacks humanismand individualism and freedom of choice,and doesn’t sell well.Human nature and national nature, be not proud. But sometimes telling it the way it is rather than the way it ought to be clears the air and clarifies the situation.

The future of ObamaCare may not be what it was cracked up to
be -upwardly mobile, virtually connected,increasingly digitally and data-driven,interconnected and interoperable,more collaborative and cooperative,less and less costly,more and more efficient and effective,and generally, better and better in every way.At least, the future hasn’t worked out that well so far. Maybe, given more time, it will.

What follows are 11 assessments of how well ObamaCare is
working out 7 years after its passage and implementation.

One,insurers are taking heavy losses from the 13
million who have signed up for the health exchanges.UnitedHealth, the biggest of them all, is pulling out of the exchanges after losing
$450 billion last year.Other major
insurers may follow,and more than half
of the insurance co-op have failed.

Two, premiums
and deductibles are spiking,often as much
as 30% to 40%,though the increases are
variable and average about 10%.

Three, the number signing up on health
exchanges have gone up by 13 million,40% less than the originally projected 20 million,at the cost of $56 billon, expected to
doublethis decade, and 11 million of the 13 million are subsidized
and are sicker than anticipated, driving up costs even faster than anticipated.

Four,the United States continues to spend 40% to
50% more than other developed nations, We lag
behind them in longevity and infant mortality rates, but we are ahead of them
in access and results of diabetes,cardiovascular,
and cancer treatments.

Five,the skeptical American public
opposes ObamaCare by consistent margins
of5% to 10%, with a slight majority
favoring a fix rather than repeal and replacement, depending how the question
is asked in polls.

Six
,a clear majority of
physicians look with disfavor upon ObamaCare, with 26% giving it a D or F
grade.Physician morale is low, physician
engagement with the system and patients is declining, and physician shortages are growing.Many physicians feel they are not part of the
health reform conversation, and significant numbers are leaving traditional
practices or are not accepting patients covered by3rd party insurance to participate
in “direct” or “cash-only” arrangements .

Seven,the nation’s health care
information system is faulty, clunky, and inadequate. Despite widespread physician and hospital adoption of electronic
health records,information systemsare not interoperative, not user-friendly,not effective in advancing quality, and are
either counter-productive or distractingin patient-physician relationships.

Eight, ObamaCare has not lived up to its promises of
lower premiums, higher quality,and
patient retention of their doctors,health plans, and hospitals.

Nine,the American middleclass is particularly
unhappy with the health care system because of a variety of factors, -
affordability,accessibility,unpredictability , and complexity.

Ten, partisanshipand disagreements amongthe major politic partiescast a pall over the future of ObamaCare and
how to fix its problems.Repeal,
replacement,elimination of individual
and employer mandates, and reduction of regulations are possible and may to
imminent.

Eleven,the technological innovations being offered by the Centers of Medicare and
Medicare Innovation -data-based algorithms
to guide care,a shift tovalue, evidence-based reimbursements, physician-hospital bundled capitated
payments rather than individualfee-for-service are on the horizon but are
controversialand do not sit well with
providers.

Wednesday, January 27, 2016

Hearts
vs Heads

The Congressional Business Office (CBO) has estimated
ObamaCare sign-ups in the final, third,and last sign-up period in the Obama administration will fall 40% short
of what the CBO originally projected,13
million rather than 20 million.Of the
13 million who signed on,11 million
received subsidies.These subsidies will
cost $56 billion in 2016 for a total of $56 billion,with the $56 billion expected to double
within the decade, if ObamaCare remains intact.This sign-up shortfall poses political
challenges for Democrats and other health law advocates and will leave an
estimated 30 million uninsured.

Tuesday, January 26, 2016

If you
are not liberal at twenty, you have no heart; if you are not conservative at
forty, you have no brain.

Winston
Churchill

I often
think it’s comical

How
nature does contrive

That’s every
boy and every gal,

Is
either a little Liberal,

Or else
a little Conservative!

W.S.
Gilbert Iolanthe II

I see by the various polls that roughly 60%% of Democrat millenials are voting for Sandersand about 60% of the middle class, 45 and older, are voting for Clinton.Similar percentage align themselves for retention
or repeal of ObamaCare.

What’s going on here is dualism.The young are idealistic.The middle class and older folks are
realistic.Or, to put it a little
differently.The young are all heart,
the older are all head.

Young millenials find themselves in a bind.They may be idealistic,but many cannot find a job.Why not, then, vote for a Democratic socialist?He promises a free college education and
free health care, both largely at someone else’s expense, and maybe,just maybe, a job at rebuilding the nation’s
infrastructure.Besides,Medicare-for-all has a nice ring to it.

Somewhere in between are 75% of voters,namely, the non-millenials, split between
liberals, independents, and conservatives.These non-millenials have been
around the block, and they have seen the consequences of liberalism – the worse
recovery from a recession since World War II with a sluggish 2% GDP growth, a
10% drop in wages and personal wealth, and a increase in health premiums of 20%
to 40% in some states.

On the other hand, they have witnessed adecline in the uninsured from 15%to 1o%, from 48 million to 30 million, of the
populationin round numbers.As a fair-minded people,they know this decline is not
inconsequential.

Which brings me to thenub of the health-heart-head problem – whether to retain or repeal
ObamaCare?The answer, it’s fair to
say, is still very much up in the air.

If you retain the law,the 10 million who have been subsidizedand the 10 million who have taken refuge inMedicaid are safe from those hard-hearted
conservatives.

If you repeal the law, you may return to a more prosperous economy,
with smaller government, less taxes and less regulations, more choice of doctors with lower premiums, and
a more hard-headed approach to the limitations of government and its excessive
spending and budget deficits.

But what about those 10 million souls who the government has
subsidized to give them access to health insurance?Surely you can’t throw them overboard

In this setting,the
conservativeshave began to formulate
their alternative to ObamaCare. In general, conservatives and Republicans have a six-point
plan:

1) Retain employer
coverage for Americans, half the population.

2) Offer tax credits
for all who qualify.

3) Assure continuous coverage protection regardless of place
of employment.

4) Reform Medicaid by allowing states to handle their distinct
problems.

5) Reform Medicare for new members, by allowing them to join
the old Medicare or enter the new managed Medicare ranks.

6) Expandhealth
savings accounts to allow workers to pick and choose and negotiate their choice
of plans and set aside unspent health dollars for a rainy day. (Lanhee Chen and James Capretta; “Instead of
ObamaCare; Giving Health-Care Power to the People,: WSJ,January 25. 2015).

This plan and other plans rely on hard-headed approaches to
health reform.The plans promise to
cover just as many people as ObamaCare, but it is still not clear specifally how they would handle those already subsidized by
government.

Monday, January 25, 2016

Like most health reform investigators, I am always in search
of metaphors.In this case, the metaphor
ise=n/c2, an analogue of Einstein’s
e-mc2.

Where:

e= energy

n =nucleus

c= speed of reform

e is the energy of the American democracy, characterized by entrepreneurial
dynamism and robust economic growth, both waiting to be unleashed.

n is the nucleus of the American nation,and its freedoms, guaranteed bythe Constitution and the Bill of Rights, and relatively
free ofgovernment coercions .

c is the speed of health reform, which has been halved by
the weight of government regulations and
market resistance.

In effect, the health reform law has split the nation’s nucleus
into two halves - one commandeered by
centralized government, the other
countermanded by decentralized market
forces.

Experiments

In both halves of the nation's nucleus, experiments being conducted, but results of
the two has yet to fuse.

On the federal half
of the nucleus, experiments include: Individual and employer mandates, Centers of Medicare and Medicaid Innovations
with accountable care
organizations,medical homes, value care and population health ,precision medicine, bundles of care based on
episodes and continuums of care,multiple government –health systems-hospitals-physicians
collaborations ,government health
exchanges, exchange co-ops.

On the market half of the nucleus, these experiments include
-Free market care,regional integrated health
organizations,retail clinics, urgicare
centers,surgicenters and other
diagnostic and treatment centers,focused factories, and numerous other consumer-oriented and empoweringentities .

Lack of
Critical Mass

What the two halves lack is strong enough particles to bombard the nucleus to achieve critical mass to sustain a health
reformchain reaction, which in the government’s case
is sufficientnew health exchange members
to make going forward feasible , and in
the market’s case adequate political support
to make their brand of reform possible.

Critical mass is essential to make a nucleus chain reaction possible,but a nuclear
reactor is needed to control the energy
release, whether that is uncontrolled government spending or free-market
excesses.

Needed:
A Nuclear Reactor

What is needed is some sort of nuclear pile to dampen the
speed of reaction in one case and to accelerateit in the other case.

Most nucleus experts agree that modulating and monitoring force must be some sort of computer-interpretative
device or group of devicesthat is
simple and useful and collaborativeand acceptable enough to bring the two sides
together in a workable mass.

That group of devices maytheFree Health Interoperative Resources
(FHIR) movement and the Argonaut Project that brings together organizationswith common standards with relevant metadata
that is collected on the front-lines of care from clinician -friendly electronic
health records that are useful,relevant
, non-intrusive,and produce results of
value (see David Shaywitz, MD, PhD, “The Last Best Chances to Achieve
Interoperability,” The Health Care Blog,January 2015, and Richard Rhodes,The
Making of the Atomic Bomb, 1986, Simon and Schuster.

The Health Reform Maze

Buy the Book

Book Description: In this first book in a series of four, Richard L. Reece, MD. provides a unique view of the roll out, and run up, of the Affordable Care Act. Reece shows in this book the progress and facets of ObamaCare's marketers and messengers, as the day approached for the launch of health insurance exchanges - the single most public and problematic portion of the new law. This is a must read for anyone who wants to chronicle this attempt to organize more than one-sixth of the U.S. economy by adding layers of federal government control and regulations.

Reece has been writing about U.S. health care for more than 45 years. His knowledge and experience, added to his keen intellect and gift of subtle humor, make this book a valuable part of anyone's collection.